Summary As the FederalSakura proceeded upstream towards the Canadian Pacific Railway (CPR) bridges 7Aand 7B,the vessel's bridge team noted that the signal lights on Bridge7A were still red. The pilot then attempted to contact the bridge operator, but there was no response. The decision was made to stop the vessel under the Honor-Mercier Bridge, downstream from bridges 7Aand7B. There was no headway, but the stern of the vessel brushed against the south pier of the Honor-Mercier Bridge. After the operator of bridges 7Aand 7Btook ill, he was replaced by another bridge operator, who immediately activated the signal for train89 operated by the Agence mtropolitaine de transport (AMT89) to proceed on Bridge7A. Subsequently, the bridge operator released Bridge7A's emergency stop push button and started raising the lift span to allow the FederalSakura to continue its voyage. Ce rapport est galement disponible en franais. Other Factual Information Particulars of the Vessel Seaway Bridges and Bridge Operator's Control Tower Photo1. View of the Honor-Mercier Bridge (Bridge6) from the control tower On the aboriginal reserve of Kahnawake, the Honor-Mercier Road Bridge and the Canadian Pacific Railway (CPR) bridges7A and 7Bspan the seaway's South Shore Canal. The Honor-Mercier Bridge, which for Seaway users is identified as Bridge6, is part of the highway that links Longueuil to Montral (see Photo1). The twin CPR bridges, located upstream from the Honor-Mercier Bridge, are equipped with a lift span to allow the passage of marine traffic. These bridges are used daily by freight trains as well as commuter trains operated by the Agence mtropolitaine de transport (AMT) (see AppendixA). Photo2. View of bridges 7A and 7B from the control tower A control tower sits on the south shore next to the CPR bridges. From the control position, the field of vision is such that it allows the operator to observe as much railway traffic as marine traffic (see Photo2). There is a control system for raising the lift spans of bridges7A and 7Band another for interlocking and switching tracks in the Seaway Canal, Adirondack Junction,and Seaway Spur zones. Lift span operations are carried out using a computer console. System programming was developed and is maintained by the St. Lawrence Seaway Management Corporation (SLSMC) (see Photo3). Track interlocking and switching is done using switches on a mimic panel supplied and maintained by CPR (see Photo4). Marine and railway systems must meet specific traffic conditions to allow the passage of either a vessel or a train. These two systems are interdependent in order to limit traffic to one mode of transport at a time. Photo3. Computer console used to operate bridges 7A and 7B Photo4. Mimic panel used to interlock and switch tracks Sequence of Events On 03 June 2005, downbound vessel CanadianOlympic and upbound vessel FederalSakura were making way in the St.Lawrence Seaway. The two vessels were proceeding toward bridges7A and7B; the CanadianOlympic anticipated passing under the bridges at approximately 1718 eastern daylight time,2 while the FederalSakura anticipated its passage at approximately1735. At 1700, southbound AMT train87 crossed Bridge7A. After the train's crossing, the bridge operator raised the lift spans of bridges7A and 7Bin anticipation of the passage of the CanadianOlympic. As planned, at 1718, it passed under the bridges. Immediately following its passage, the bridge operator lowered the lift spans to allow AMT passenger train89 southbound and AMT passenger train 90 northbound to pass over the bridges. At 1723, the lift spans were fully lowered and, at 1728, the emergency stop push button was activated for Bridge7A. This action eliminates all commands capable of moving the bridge span until the operator releases the button. At 1734, AMT train89 arrived at Bridge7A, but the locomotive engineer did not have the green light to cross the bridge. At 1735, AMT train90 arrived at Bridge7B and also encountered a red light (see AppendixC). At 1740, the rail traffic controller (RTC), based in Montral, noted the stoppage of both AMT trains and attempted to telephone the bridge operator. At 1741, the RTC reached the bridge operator. The bridge operator was incoherent, and the RTC concluded that medical assistance was required. Accordingly, the RTC dispatched an ambulance as well as another bridge operator. At 1736, the FederalSakura, proceeding at a speed of 6.6knots, met the CanadianOlympic below buoys V29and V30,which are located approximately one nautical mile downstream from bridges7A and7B. Noting that bridges 7Aand 7Bwere still lowered, the pilot of the FederalSakura contacted Seaway Beauharnois to enquire about the situation. Seaway Beauharnois immediately attempted to reach the bridge operator by telephone and very high frequency (VHF) radiotelephone, but to no avail. The ship traffic controller then reached the security guard to check out the situation. At 1745, when the FederalSakura passed the whistle sign, approximately 0.71nautical mile downstream from the bridges, the bridge team noted that the red signal lights on the CPR bridge were not flashing; flashing lights indicate that the lift span is being raised. The pilot called the bridge operator via radiotelephone on channel 14VHF, but there was no answer. Then, the captain and the pilot decided to stop the vessel under Honor-Mercier Bridge, which is located 0.16nautical miles downstream from the CPR bridges. An emergency stop manoeuvre was undertaken; the main engine was reversed while the vessel was still proceeding at a speed of 5.2knots; when the vessel passed under the Honor-Mercier Bridge, the two forward anchors were dropped. In the meantime, at 1752, the bridge operator managed to raise the lift span of Bridge7B but was unable to raise the lift span of Bridge7A. At 1758, the vessel had no headway, and the stern brushed the south pier of the Honor-Mercier Bridge, without sustaining any damage. Subsequently, the vessel was manoeuvred to the centre of the channel, some 100metres from Bridge7A. At 1805, the relief bridge operator arrived at the control station in the tower and immediately activated the signal to allow AMT train89 to pass on Bridge7A. Subsequently, the bridge operator released Bridge7A's emergency stop push button and, at 1822, started to raise the bridge's lift span. At 1825, the red signal lights were deactivated and the green signal lights on the CPR bridges were activated. The vessel weighed its anchors and continued its voyage under the CPR bridges. Meanwhile, the ambulance attendants assisted the bridge operator and transported him to Anna-Laberge Hospital in Chteauguay, Quebec. Duties and Medical Condition of the Bridge Operator The bridge operator is employed by CPR. He works as an Interlocking RTC at Seaway Interlocking and is supervised by the RTC of the Adirondack Subdivision. He maintains contact by telephone and radiotelephone with a marine traffic controller based at the Saint-Lambert traffic station (Seaway Beauharnois). Bridge operation along with track interlocking and switching are all performed by the bridge operator; presently, these duties cannot be performed remotely. In other words, the bridge operator operates the bridges, including rail signal and interlocking on his own - a condition prone to single-point failure, as in this occurrence. Under Transport Canada Railway Rules Governing Safety Critical Positions,3 an Interlocking RTC function is designated a safety-critical position. In 2001, Transport Canada announced the coming into force of the Railway Medical Rules for Positions Critical to Safe Railway Operations, which established a new process for medical assessments and defined medical fitness for duty requirements. A manual was prepared to provide railway companies with the information needed to enforce said rules. In this manual, diabetes is referred to as a health problem to be assessed on an individual basis. The bridge operator was diabetic and was being treated with insulin and an oral hypoglycaemic drug. He was under regular care of doctors, and the railway company had been aware of his medical condition since spring 2002. According to the CPR's chief medical officer, the bridge operator most likely suffered a severe episode of hypoglycaemia, in modifying his diet in an attempt to lose weight, which affected his cognitive function including his alertness, judgment and insight, as a result of an abnormal lowering of blood sugar. The Security Guard The security guard is an employee of a security guard company contracted by the SLSMC. The position's duties include ensuring that no persons are on the lift spans before and during lifting. An audible signal warns the security guard when lift spans are going to be raised or lowered. He is not trained to perform the duties of the bridge operator. The security guard's working office building is separate from the bridge operator's office building. Defence in the Event of Deficiencies The two modes of transport share similar operating practices. Coupled with rail advance signs and marine lights and signs, red and green signal lights are used to designate which party has the right of way. The lights must be green to proceed on or under bridges. For rail traffic, trains must come to a complete stop before passing the governing red signal (see AppendixC); for marine traffic, vessels must stop (with or without dropping anchor) if the red light is in a steady mode (see AppendixD). In this case, the trains and the vessel were able to stop.4 Similar Occurrence Similar circumstances to these were revealed in the investigation of bulk carrier Windoc's striking of the lift span of Bridge11 in the Seaway's Welland Canal in2001.5 That investigation revealed the following: The operation of any lift bridge involves close interaction between the operator and traffic control centre personnel; the bridge operator represented the sole line of defence, someone who could - and was required to - ensure that the transit of the vessel under the bridge was carried out safely. It is likely that the operator's performance was impaired at the time of the occurrence. The SLSMC is responsible for operations and Seaway structure maintenance in Canada. Bridge operators very often work alone, thereby providing little opportunity for supervisors to ensure that operators are able to consistently perform their job functions in an appropriate and safe manner. Following this occurrence, action was taken to improve bridge protection to avoid future contact with vessels passing through the Welland Canal. Motion detectors were installed to detect vessels passing under the bridges. The SLSMC also installed motion detectors to detect the presence of vessels passing under the bridges in the Montral/Lake Ontario section, namely the Saint-Louis Bridge (Bridge9), Valleyfield Bridge (Bridge10), and CPR bridges7A and7B. At that time, the SLSMC was also developing plans for the remote operation of the Saint-Louis Bridge. The following action has been taken by the SLSMC: The control centre must make random telephone calls to the bridge operators in the Montral/Lake Ontario section. All free-standing lift bridges on the Welland Canal are now remotely operated from a control centre. The bridge operator is now required to make a VHF call to the vessel. At isolated free-standing lift bridges, the automatic identification system (AIS) is now used to alert bridge operators of an approaching vessel. A bridge operator is required to communicate with a vessel before lowering the bridge.